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Villarroel LR, Arabia FA, Tams EM, Hu C, Smith LT, Dalton HJ, Molitor MS, Chapital AB, Padiyar JP, Riley RD, Mosier JM. Fair and Just Opportunity: Streamlining COVID-19 Extracorporeal Membrane Oxygenation Referrals on a Statewide Platform to Enhance Equity. Ann Am Thorac Soc 2024; 21:1375-1378. [PMID: 39012175 PMCID: PMC11451882 DOI: 10.1513/annalsats.202310-907ip] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 07/11/2024] [Indexed: 07/17/2024] Open
Affiliation(s)
| | - Francisco A. Arabia
- Advanced Heart Program, Banner Health–University of Arizona, Phoenix, Arizona
| | - Erin M. Tams
- Arizona Surge Line, Arizona Department of Health Services, Phoenix, Arizona
| | - Chengcheng Hu
- Epidemiology and Biostatistics, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona
- Biostatistics and Study Design Services, The University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Luke T. Smith
- Arizona Surge Line, Arizona Department of Health Services, Phoenix, Arizona
| | | | - Mark S. Molitor
- Pediatric Surgery, Department of Surgery, Phoenix Children’s Hospital, Phoenix, Arizona
| | | | - Josna P. Padiyar
- Department of Critical Care Medicine, Dignity Health, Phoenix, Arizona
| | | | - Jarrod M. Mosier
- Department of Emergency Medicine and
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, The University of Arizona College of Medicine, Tucson, Arizona; and
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2
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Bibler TM, Zainab A. Withdrawing extra corporeal membrane oxygenation (ECMO) against a family's wishes: Three permissible scenarios. J Heart Lung Transplant 2023; 42:849-852. [PMID: 36972748 DOI: 10.1016/j.healun.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
The ethical permissibility of unilaterally withdrawing life-sustaining technologies has been a perennial topic in transplant and critical care medicine, often focusing on CPR and mechanical ventilation. The permissibility of unilateral withdrawal of extracorporeal membrane oxygenation (ECMO) has been discussed sparingly. When addressed, authors have appealed to professional authority rather than substantive ethical analysis. In this Perspective, we argue that there are at least three (3) scenarios wherein healthcare teams would be justified in unilaterally withdrawing ECMO, despite the objections of the patient's legal representative. The ethical considerations that provide the groundwork for these scenarios are, primarily: equity, integrity, and the moral equivalence between withholding and withdrawing medical technologies. First, we place equity in the context of crisis standards of medicine. After this, we discuss professional integrity as it relates to the innovative usage of medical technologies. Finally, we discuss the ethical consensus known at the "equivalence thesis." Each of these considerations include a scenario and justification for unilateral withdrawal. We also provide three (3) recommendations that aim at preventing these challenges at their outset. Our conclusions and recommendations are not meant to be blunt arguments that ECMO teams wield whenever disagreement about the propriety of continued ECMO support arises. Instead, the onus will be on individual ECMO programs to evaluate these arguments and decide if they represent sensible, correct, and implementable starting points for clinical practice guidelines or policies.
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Affiliation(s)
- Trevor M Bibler
- Center for Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.
| | - Asma Zainab
- Department of Cardiovascular Anesthesia, Weill Cornell Medical College, New York, New York; Intensivist Cardiovascular Surgical ICU, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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Bilodeau KS, Badulak J, Bulger E, Stewart B, Mandell SP, Taylor M, Condella A, Carlson MD, Kohl LP, Simpson NS, Heather B, Prekker ME, Johnson NJ. Implementation of Extracorporeal Membrane Oxygenation Without On-Site Cardiac Surgery or Perfusion Support: A Tale of Two County Hospitals. ASAIO J 2023; 69:e223-e229. [PMID: 36727856 DOI: 10.1097/mat.0000000000001883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Patients with refractory respiratory and cardiac failure may present to noncardiac surgery centers. Prior studies have demonstrated that acute care surgeons, intensivists, and emergency medicine physicians can safely cannulate and manage patients receiving extracorporeal membrane oxygenation (ECMO). Harborview Medical Center (Harborview) and Hennepin County Medical Center (Hennepin) are both urban, county-owned, level 1 trauma centers that implemented ECMO without direct, on-site cardiac surgery or perfusion support. Both centers 1) use an ECMO specialist model staffed by specially trained nurses and respiratory therapists and 2) developed comparable training curricula for ECMO specialists, intensivists, surgeons, and trainees. Each program began with venovenous ECMO to provide support for refractory hypoxemic respiratory failure and subsequently expanded to venoarterial ECMO support. The coronavirus disease 2019 (COVID-19) pandemic created an impetus for restructuring, with each program creating a consulting service to facilitate ECMO delivery across multiple intensive care units (ICUs) and to promote fellow and resident training and experience. Both Harborview and Hennepin, urban county hospitals 1,700 miles apart in the United States, independently implemented and operate adult ECMO programs without involvement from cardiovascular surgery or perfusion services. This experience further supports the role of ECMO specialists in the delivery of extracorporeal life support.
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Affiliation(s)
- Kyle S Bilodeau
- From the Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Jenelle Badulak
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Department of Emergency Medicine, Harborview Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Eileen Bulger
- From the Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Barclay Stewart
- From the Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Samuel P Mandell
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Mark Taylor
- Critical Care Nursing, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Anna Condella
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Department of Emergency Medicine, Harborview Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Michelle D Carlson
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare Systems, Minneapolis, Minnesota
| | - Louis P Kohl
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare Systems, Minneapolis, Minnesota
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin Healthcare Systems, Minneapolis, Minnesota
| | - Beth Heather
- Critical Care Nursing, Hennepin Healthcare Systems, Minneapolis, Minnesota
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin Healthcare Systems, Minneapolis, Minnesota
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Department of Emergency Medicine, Harborview Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
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4
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Gannon WD, Trindade AJ, Stokes JW, Casey JD, Benson C, Patel YJ, Pugh ME, Semler MW, Bacchetta M, Rice TW. Extracorporeal Membrane Oxygenation Selection by Multidisciplinary Consensus: The ECMO Council. ASAIO J 2023; 69:167-173. [PMID: 35544441 DOI: 10.1097/mat.0000000000001757] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has increased the demand for extracorporeal membrane oxygenation (ECMO) and introduced distinct challenges to patient selection for ECMO. Standardized processes for patient selection amidst resource limitations are lacking, and data on ECMO consults are underreported. We retrospectively reviewed consecutive adult ECMO consults for acute respiratory failure received at a single academic medical center from April 1, 2020, to February 28, 2021, and evaluated the implementation of a multidisciplinary selection committee (ECMO Council) and standardized framework for patient selection for ECMO. During the 334-day period, there were 202 total ECMO consults; 174 (86.1%) included a diagnosis of COVID-19. Among all consults, 157 (77.7%) were declined and 41 (20.3%) resulted in the initiation of ECMO. Frequent reasons for decline included the presence of multiple relative contraindications (n = 33), age greater than 60 years (n = 32), and resource limitations (n = 27). The ECMO Council deliberated on every case in which an absolute contraindication was not present (n = 96) via an electronic teleconference platform. Utilizing multidisciplinary consensus together with a standardized process for patient selection in ECMO is feasible during a pandemic and may be reliably exercised over time. Whether such an approach is feasible at other centers remains unknown.
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Affiliation(s)
- Whitney D Gannon
- From the Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anil J Trindade
- From the Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Casey
- From the Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clayne Benson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yatrik J Patel
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meredith E Pugh
- From the Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W Semler
- From the Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- From the Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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5
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Appel JM. The draw of the few: the challenge of crisis guidelines for extremely scarce resources. JOURNAL OF MEDICAL ETHICS 2022; 48:1032-1036. [PMID: 34615697 DOI: 10.1136/medethics-2021-107519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/25/2021] [Indexed: 06/13/2023]
Abstract
The COVID-19 pandemic has focused considerable attention on crisis standards of care (CSCs). Most public CSCs at present are effective tools for allocating scarce but not uncommon resources (like ventilators and dialysis machines). However, a different set of challenges arise with regard to extremely scarce resources (ESRs), where the number of patients in need may exceed the availability of the intervention by magnitudes of hundreds or thousands. Using the allocation of extracorporeal membrane oxygenation machines as a case study, this paper argues for a different set of CSCs specifically for ESRs and explores four principles (transparency, uniformity, equity and impact) that should shape such guidelines.
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Affiliation(s)
- Jacob M Appel
- Psychiatry and Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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6
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Selection criteria and triage in extracorporeal membrane oxygenation during coronavirus disease 2019. Curr Opin Crit Care 2022; 28:674-680. [PMID: 36302196 DOI: 10.1097/mcc.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Coronavirus disease 2019 (COVID-19) pandemic changed the way we had to approach hospital- and intensive care unit (ICU)-related resource management, especially for demanding techniques required for advanced support, including extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS Availability of ICU beds and ECMO machines widely varies around the world. In critical conditions, such a global pandemic, the establishment of contingency capacity tiers might help in defining to which conditions and subjects ECMO can be offered. A frequent reassessment of the resource saturation, possibly integrated within a regional healthcare coordination system, may be of help to triage the patients who most likely will benefit from advanced techniques, especially when capacities are limited. SUMMARY Indications to ECMO during the pandemic should be fluid and may be adjusted over time. Candidacy of patients should follow the same prepandemic rules, taking into account the acute disease, the burden of any eventual comorbidity and the chances of a good quality of life after recovery; but the current capacity of healthcare system should also be considered, and frequently reassessed, possibly within a wide hub-and-spoke healthcare system. VIDEO ABSTRACT http://links.lww.com/COCC/A43.
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7
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Gottula AL, Shaw CR, Gorder KL, Lane BH, Latessa J, Qi M, Koshoffer A, Al-Araji R, Young W, Bonomo J, Langabeer JR, Yannopoulos D, Henry TD, Hsu CH, Benoit JL. Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model. Resuscitation 2022; 180:111-120. [PMID: 36183812 DOI: 10.1016/j.resuscitation.2022.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.S. requires a better understanding of how these factors interact with transport time to ECPR centers. METHODS We constructed a Geographic Information System (GIS) model to estimate the number of ECPR candidates in the U.S. We utilized a Resuscitation Outcome Consortium (ROC) database to model time-dependent rates of ECPR eligibility and the Cardiac Arrest Registry to Enhance Survival (CARES) registry to determine the total number of OHCA patients who meet pre-specified ECPR criteria within designated transportation times. The combined model was used to estimate the total number of ECPR candidates. RESULTS There were 588,203 OHCA patients in the CARES registry from 2013 to 2020. After applying clinical eligibility criteria, 22,104 (3.76%) OHCA patients were deemed eligible for ECPR. The rate of ROSC increased with longer resuscitation time, which resulted in fewer ECPR candidates. The proportion of OHCA patients eligible for ECPR increased with older age cutoffs. Only 1.68% (9,889/588,203) of OHCA patients in the U.S. were eligible for ECPR based on a 45-minute transportation time to an ECMO-ready center model. CONCLUSIONS Less than 2% of OHCA patients are eligible for ECPR in the U.S. GIS models can identify the impact of clinical criteria, transportation time, and hospital capabilities on ECPR eligibility to inform future implementation strategies.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, United States; Department of Anesthesiology, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States.
| | - Christopher R Shaw
- Department of Medicine Division of Pulmonary and Critical Care, Oregon Health and Science University, United States
| | - Kari L Gorder
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, United States.
| | - Jennifer Latessa
- Department of Planning, The University of Cincinnati, United States.
| | - Man Qi
- Department of Geography and Geographic Information System, The University of Cincinnati, United States.
| | - Amy Koshoffer
- University of Cincinnati Libraries, The University of Cincinnati, United States.
| | - Rabab Al-Araji
- Department of Emergency Medicine, Emory University, United States; The Cardiac Arrest Registry to Enhance Survival, United States.
| | - Wesley Young
- College of Medicine, The University of Cincinnati, United States
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, United States; Department of Neurosurgery, University of Cincinnati, United States.
| | - James R Langabeer
- Department of Emergency, Medicine McGovern School of Medicine, The University of Texas Health Center, United States; UT School of Public Health, The University of Texas Health Center, United States; School of Biomedical Informatics, The University of Texas Health Center, United States.
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States; Department of Surgery, University of Michigan, United States.
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, United States.
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8
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Essig R, Sundland R, Chokshi N. Lessons Learned from Extracorporeal Membrane Oxygenation Use During the COVID-19 Pandemic. Pediatr Ann 2022; 51:e281-e285. [PMID: 35858215 DOI: 10.3928/19382359-20220504-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
With the rise of the coronavirus disease 2019 (COVID-19) respiratory pandemic, there has been an increased need to consider the use of extracorporeal membrane oxygenation (ECMO) technology. In the early phases of the pandemic, adults constituted most of the critically ill patients, and ECMO management strategies were developed for use in this population. During the course of the pandemic, there has been a rise in the number of critically ill children infected with COVID-19. Although ECMO has been used in the care of pediatric patients for more than half a century, it has been challenging to apply the lessons learned from adult patients with COVID-19 directly to critically ill children for whom ECMO is under consideration. This article reviews ECMO technology and highlights a number of important changes in pediatric ECMO regarding those patients infected with COVID-19. [Pediatr Ann. 2022;51(7):e281-e285.].
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9
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Han JJ, Shin M, Patrick WL, Rao A, Olia SE, Helmers MR, Iyengar A, Kelly JJ, Smood B, Gutsche JT, Bermudez C, Cevasco M. How Should ECMO Be Used Under Conditions of Severe Scarcity? A Population Study of Public Perception. J Cardiothorac Vasc Anesth 2022; 36:1662-1669. [PMID: 34218997 PMCID: PMC8249692 DOI: 10.1053/j.jvca.2021.05.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/12/2021] [Accepted: 05/30/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To assess societal preferences regarding allocation of extracorporeal membrane oxygenation (ECMO) as a rescue option for select patients with coronavirus disease 2019 (COVID-19). DESIGN Cross-sectional survey of a nationally representative sample. SETTING Amazon Mechanical Turk platform. PARTICIPANTS In total, responses from 1,041 members of Amazon Mechanical Turk crowd-sourcing platform were included. Participants were 37.9 ± 12.6 years old, generally white (65%), and college-educated (66.1%). Many reported working in a healthcare setting (22.5%) and having a friend or family member who was admitted to the hospital (43.8%) or died from COVID-19 (29.9%). MEASUREMENTS AND MAIN RESULTS Although most reported an unwillingness to stay on ECMO for >one week without signs of recovery, participants were highly supportive of ECMO utilization as a life-preserving technique on a policy level. The majority (96.7%) advocated for continued use of ECMO to treat COVID patients during periods of resource scarcity but would prioritize those with highest likelihood of recovery (50%) followed by those who were sickest regardless of survival chances (31.7%). Patients >40 years old were more likely to prefer distributing ECMO on a first-come first-served basis (21.5% v 13.3%, p < 0.05). CONCLUSION Even though participants expressed hesitation regarding ECMO in personal circumstances, they were uniformly in support of using ECMO to treat COVID patients at a policy level for others who might need it, even in the setting of severe scarcity.
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Affiliation(s)
- Jason J. Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William L. Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Akhil Rao
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Salim E. Olia
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mark R. Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John J. Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jacob T. Gutsche
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA,Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA,Address correspondence to Marisa Cevasco, MD, MPH, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA
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10
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Evaluation of Minnesota Score in the Allocation of Venovenous Extracorporeal Membrane Oxygenation During Resource Scarcity. Crit Care Res Pract 2022; 2022:2773980. [PMID: 35402045 PMCID: PMC8985705 DOI: 10.1155/2022/2773980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background In this study, we evaluate the previously reported novel Minnesota Score for association with in-hospital mortality and allocation of venovenous extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome with or without SARS-CoV-2 pneumonia. Methods This was a retrospective cohort study across four extracorporeal membrane oxygenation centers in Minnesota. Logistic regression was used to assess the relationship between the scores and in-hospital mortality, duration of ECMO cannulation, and discharge disposition. Priority groups were established statistically by maximizing the sum of sensitivity and specificity and compared to the previous qualitatively established priority groups. Results Of 124 patients included in the study, 38% were treated for COVID-19 acute respiratory distress syndrome. The median age was 48 years, and 73% were male. The in-hospital mortality rate was 38%. The Minnesota Score was significantly associated with in-hospital mortality only (OR 1.13, p=0.02). Statistically determined cut points were similar to qualitative cut points. SARS-CoV-2 status did not change the findings. Conclusions In our patient cohort, the Minnesota Score is associated with increased mortality. With further validation, proposed priority groups could be utilized for allocation of ECMO in times of increasing scarcity.
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Bohman JJKK, Seelhammer TG, Mazzeffi M, Gutsche J, Ramakrishna H. The Year in Extracorporeal Membrane Oxygenation: Selected Highlights From 2021. J Cardiothorac Vasc Anesth 2022; 36:1832-1843. [PMID: 35367120 DOI: 10.1053/j.jvca.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/11/2022]
Abstract
This review summarizes the extracorporeal membrane oxygenation (ECMO) or extracorporeal life support literature published in 2021. This Selected Highlights article is not intended to be an exhaustive review of the literature, but rather a summarizing of key themes that developed in the ECMO literature during 2021. The primary topics presented include the following: ECMO for coronavirus disease 2019, extracorporeal cardiopulmonary resuscitation, periprocedural cardiopulmonary support with ECMO, and anticoagulation for ECMO.
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Affiliation(s)
- John J Kyle K Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care Medicine, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Hick JL, Hanfling D, Wynia M. Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19. Jt Comm J Qual Patient Saf 2022; 48:354-361. [PMID: 35595654 PMCID: PMC8828442 DOI: 10.1016/j.jcjq.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Hick JL, Hanfling D, Wynia MK, Toner E. Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do? NAM Perspect 2021; 2021:202108e. [PMID: 34611605 DOI: 10.31478/202108e] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- John L Hick
- Hennepin Healthcare and University of Minnesota
| | | | | | - Eric Toner
- Johns Hopkins Center for Health Security
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14
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Odish MF, Yi C, Chicotka S, Genovese B, Golts E, Madani M, Owens RL, Pollema T. Implementation and Outcomes of a Mobile Extracorporeal Membrane Oxygenation Program in the United States During the Coronavirus Disease 2019 Pandemic. J Cardiothorac Vasc Anesth 2021; 35:2869-2874. [PMID: 34176676 PMCID: PMC8152207 DOI: 10.1053/j.jvca.2021.05.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/02/2021] [Accepted: 05/21/2021] [Indexed: 01/19/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic began in the United States around March 2020. Because of limited access to extracorporeal membrane oxygenation (ECMO) in the authors' region, a mobile ECMO team was implemented by April 2020 to serve patients with COVID-19. Several logistical and operational needs were assessed and addressed to ensure a successful program, including credentialing, equipment management, and transportation. A multidisciplinary team was included in the planning, decision-making, and implementation of the mobile ECMO. From April 2020 to January 2021, mobile ECMO was provided to 22 patients in 13 facilities across four southern California counties. The survival to hospital discharge of patients with COVID-19 who received mobile ECMO was 52.4% (11 of 21) compared with 45.2% (14 of 31) for similar patients cannulated in-house. No significant patient or transportation complications occurred during mobile ECMO. Neither the ECMO nor transport teams experianced unprotected exposures to or infections with severe acute respiratory syndrome coronavirus 2. Herein, the implementation of the mobile ECMO team is reviewed, and patient characteristics and outcomes are described.
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Affiliation(s)
- Mazen F Odish
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, CA.
| | - Cassia Yi
- Department of Nursing, University of California, San Diego, San Diego, CA
| | - Scott Chicotka
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, San Diego, CA
| | - Bradley Genovese
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, San Diego, CA
| | - Eugene Golts
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, San Diego, CA
| | - Michael Madani
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, San Diego, CA
| | - Robert L Owens
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, CA
| | - Travis Pollema
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, San Diego, CA
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15
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Carlisle EM, Bagwell CE. Ethical challenges with decisions to withhold or withdraw resuscitation in pediatric surgery. Semin Pediatr Surg 2021; 30:151096. [PMID: 34635284 DOI: 10.1016/j.sempedsurg.2021.151096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Providers often dispute the ethical equivalence of withholding and withdrawing care, despite theoretical frameworks that support equivalency. We highlight two cases, one where providers express concern with initiation of aggressive resuscitation and another where providers experience emotional distress from the decision to cease resuscitation. Both cases illustrate how the ethical challenges encountered can result in high levels of provider distress. Mitigation of this moral distress by team members will require an improved understanding of available evidence in the literature and active discussion by debriefing after a child dies. Medical staff and national organizations can help recognize that these patient events contribute to provider burnout and facilitate the design and support of programs to increase provider resiliency.
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Affiliation(s)
- Erica M Carlisle
- Department of Surgery, Division of Pediatric Surgery, University of Iowa Hospitals and Clinics, USA; Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, USA.
| | - Charles E Bagwell
- Department of Surgery, Division of Pediatric Surgery, Virginia Commonwealth University/Medical College of Virginia, USA
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16
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Decision-Making, Ethics, and End-of-Life Care in Pediatric Extracorporeal Membrane Oxygenation: A Comprehensive Narrative Review. Pediatr Crit Care Med 2021; 22:806-812. [PMID: 33989251 DOI: 10.1097/pcc.0000000000002766] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric extracorporeal membrane oxygenation is associated with significant morbidity and mortality. We sought to summarize literature on communication and decision-making, end-of-life care, and ethical issues to identify recommended approaches and highlight knowledge gaps. DATA SOURCES PubMed, Embase, Web of Science, and Cochrane Library. STUDY SELECTION We reviewed published articles (1972-2020) which examined three pediatric extracorporeal membrane oxygenation domains: 1) decision-making or communication between clinicians and patients/families, 2) ethical issues, or 3) end-of-life care. DATA EXTRACTION Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. DATA SYNTHESIS Of 2,581 publications screened, we identified one systematic review and 35 descriptive studies. No practical guides exist for communication and decision-making in pediatric extracorporeal membrane oxygenation. Conversation principles and parent/clinician perspectives are described. Ethical issues related to consent, initiation, discontinuation, resource allocation, and research. No patient-level synthesis of ethical issues or end-of-life care in pediatric extracorporeal membrane oxygenation was identified. CONCLUSIONS Despite numerous ethical issues reported surrounding pediatric extracorporeal membrane oxygenation, we found limited patient-level research and no practical guides for communicating with families or managing extracorporeal membrane oxygenation discontinuation.
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Hick JL, Hanfling D, Wynia M, Toner E. Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do? NAM Perspect 2021. [DOI: 10.31478/202108d] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- John L. Hick
- Hennepin Healthcare and the University of Minnesota
| | | | | | - Eric Toner
- Johns Hopkins Center for Health Security
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18
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Consenso ECMO colombiano para paciente con falla respiratoria grave asociada a COVID-19. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2021. [PMCID: PMC7538114 DOI: 10.1016/j.acci.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Antecedentes y objetivos La epidemia de COVID-19 ha creado un desafío sin precedentes en el sistema de salud, generando una demanda creciente. Alrededor del 5% de los pacientes diagnosticados con esta infección requieren ingreso a cuidados intensivos principalmente para soporte ventilatorio con ventilación mecánica por un síndrome de dificultad respiratoria aguda (SDRA) de moderado a grave. Las mortalidades reportadas pueden ser muy altas. Las dos principales causas de muerte en esta infección son la hipoxemia refractaria asociada al SDRA y el shock con insuficiencia orgánica múltiple. La oxigenación con membrana extracorpórea (ECMO) se ha utilizado en pacientes con hipoxemia refractaria sin respuesta a manejo con ventilación mecánica protectora, ventilación en posición prono y relajación muscular. La Organización Mundial de la Salud recomienda considerar ECMO en pacientes adultos y pediátricos con COVID-19 y SDRA refractario, si hay un equipo de expertos disponible. Métodos Se utilizó la metodología de consenso formal para generar el Consenso ECMO en la infección SARS-CoV-2 con la mejor evidencia disponible. El desarrollo del consenso combina las técnicas de selección, síntesis, evaluación y gradación de la evidencia: formulación de la pregunta PICO [P - Paciente, Problema o Población. I - Intervención. C - Comparación, control. O - Outcome(s) (muerte)], estrategias de búsqueda sistemática y técnicas de síntesis (metaanálisis). La evaluación de la calidad de la evidencia y la graduación de la fuerza de las recomendaciones se realizó con la estrategia GRADE, generando al final recomendaciones para los tópicos más relevantes del manejo del paciente con COVID-19 candidato a ECMO y por técnica de consenso formal (Delphi). Resultados El consenso colombiano para pacientes con falla respiratoria grave asociada a COVID-19 proporciona un resumen de la evidencia sobre el uso de ECMO en insuficiencia respiratoria hipoxémica aguda grave asociada con la infección SARS-CoV-2, dando recomendaciones sobre sus indicaciones, contraindicaciones, consideraciones y la implementación del grupo ECMOred Colombia. Conclusiones El consenso colombiano de ECMO es un documento de guía y consulta para el manejo de pacientes con insuficiencia respiratoria aguda grave refractaria y disfunción cardiovascular asociada con COVID-19 candidatos para ECMO.
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Odish M, Yi C, Eigner J, Kenner Brininger A, Koenig KL, Willms D, Lerum S, McCaul S, Boyd King A, Sutherland G, Cederquist L, Owens RL, Pollema T. The Southern California Extracorporeal Membrane Oxygenation Consortium During the Coronavirus Disease 2019 Pandemic. Disaster Med Public Health Prep 2021; 16:1-8. [PMID: 34099097 PMCID: PMC8314051 DOI: 10.1017/dmp.2021.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/10/2021] [Accepted: 05/29/2021] [Indexed: 02/07/2023]
Abstract
In March 2020, at the onset of the coronavirus disease 2019 (COVID-19) pandemic in the United States, the Southern California Extracorporeal Membrane Oxygenation (ECMO) Consortium was formed. The consortium included physicians and coordinators from the 4 ECMO centers in San Diego County. Guidelines were created to ensure that ECMO was delivered equitably and in a resource effective manner across the county during the pandemic. A biomedical ethicist reviewed the guidelines to ensure ECMO use would provide maximal community benefit of this limited resource. The San Diego County Health and Human Services Agency further incorporated the guidelines into its plans for the allocation of scarce resources. The consortium held weekly video conferences to review countywide ECMO capacity (including census and staffing), share data, and discuss clinical practices and difficult cases. Equipment exchanges between ECMO centers maximized regional capacity. From March 1 to November 30, 2020, consortium participants placed 97 patients on ECMO. No eligible patients were denied ECMO due to lack of resources or capacity. The Southern California ECMO Consortium may serve as a model for other communities seeking to optimize ECMO resources during the current COVID-19 or future pandemics.
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Affiliation(s)
- Mazen Odish
- University of California, San Diego Health, San Diego, California, USA
| | - Cassia Yi
- University of California, San Diego Health, San Diego, California, USA
| | | | | | - Kristi L. Koenig
- County of San Diego Health and Human Services Agency, San Diego, California, USA
| | | | - Suzan Lerum
- Sharp HealthCare, San Diego, California, USA
| | | | | | | | | | - Robert L. Owens
- University of California, San Diego Health, San Diego, California, USA
| | - Travis Pollema
- University of California, San Diego Health, San Diego, California, USA
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20
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Dao B, Savulescu J, Suen JY, Fraser JF, Wilkinson DJC. Ethical factors determining ECMO allocation during the COVID-19 pandemic. BMC Med Ethics 2021; 22:70. [PMID: 34074282 PMCID: PMC8169422 DOI: 10.1186/s12910-021-00638-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/24/2021] [Indexed: 01/15/2023] Open
Abstract
Background ECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations. Methods An online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic. Results When initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, (p < 0.001). If a full unit were referred a good candidate for ECMO, participants were more likely during the pandemic to consider discontinuing ECMO from a current patient with low chance of survival (53% during pandemic vs. 33% prior p = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%). Conclusions We found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00638-y.
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Affiliation(s)
- Bernadine Dao
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes St, Oxford, OX1 1PT, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes St, Oxford, OX1 1PT, UK.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Dominic J C Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes St, Oxford, OX1 1PT, UK. .,John Radcliffe Hospital, Oxford, UK. .,Murdoch Children's Research Institute, Melbourne, Australia.
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21
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Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67:485-495. [PMID: 33657573 PMCID: PMC8078022 DOI: 10.1097/mat.0000000000001422] [Citation(s) in RCA: 250] [Impact Index Per Article: 83.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
DISCLAIMER This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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Affiliation(s)
- Jenelle Badulak
- From the Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - M. Velia Antonini
- General ICU, University Hospital of Parma, Parma, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | | | - Lara Shekerdemian
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Raman
- Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew L. Paden
- Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | | | - Nicholas Barrett
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Mark T. Ogino
- Nemours Children’s Health System, Wilmington, Delaware
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | | | - Ahmed A. Rabie
- Critical Care ECMO Service, King Saud Medical City, Ministry Of Health (MOH), Riyadh, Saudi Arabia
| | - Leonardo Salazar
- Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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22
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Bergman ZR, Wothe JK, Alwan FS, Dunn A, Lusczek ER, Lofrano AE, Tointon KM, Doucette M, Bohman JK, Saavedra-Romero R, Prekker ME, Brunsvold ME. The Use of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Infection: One Region's Comprehensive Experience. ASAIO J 2021; 67:503-510. [PMID: 33492851 PMCID: PMC8078021 DOI: 10.1097/mat.0000000000001403] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Severe acute respiratory distress syndrome (ARDS) unresponsive to conventional intensive care unit (ICU) management is an accepted indication for venovenous extracorporeal membrane oxygenation (V-V ECMO) support. The frequency with which patients with coronavirus disease 2019 (COVID-19) pneumonia are selected for V-V ECMO has not been described. This was a cohort study including all patients placed on either V-V ECMO or venoarteriovenous ECMO at the four adult ECMO Centers of Excellence. Primary outcomes evaluated were survival to decannulation from the ECMO circuit, survival to discharge, and 60-day survival. Secondary outcomes were hospital length of stay (LOS), ICU LOS, length of ECMO cannulation, and length of intubation. During the study period, which corresponded to the first surge in COVID-19 hospitalizations in Minnesota, 35 patients with ARDS were selected for V-V ECMO support out of 1,849 adult ICU patients with COVID-19 infection in the state (1.9% incidence; 95% CI, 1.3-2.6%). This represents 46 (95% CI, 34-61) expected V-V ECMO patients per 100,000 confirmed positive cases of COVID-19. Twenty-six of the 35 patients (74.3%) supported with V-V ECMO survived to 60-day post-ECMO decannulation. Recent studies have demonstrated ongoing success rescuing patients with severe ARDS in COVID-19 infection. Our data add to the support of ECMO and the consideration for encouraging cooperation among regional ECMO centers to ensure access to this highest level of care. Finally, by evaluating all the patients of a single region, we estimate overall need for this resource intensive intervention based on the overall number of COVID-19 cases and ICU admissions.
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Affiliation(s)
- Zachary R. Bergman
- From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | | | - Fatima S. Alwan
- Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Alex Dunn
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | | | - Arianna E. Lofrano
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | - Kelly M. Tointon
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Melissa Doucette
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - John K. Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ramiro Saavedra-Romero
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota
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23
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Lebreton G, Schmidt M, Ponnaiah M, Folliguet T, Para M, Guihaire J, Lansac E, Sage E, Cholley B, Mégarbane B, Cronier P, Zarka J, Da Silva D, Besset S, Morichau-Beauchant T, Lacombat I, Mongardon N, Richard C, Duranteau J, Cerf C, Saiydoun G, Sonneville R, Chiche JD, Nataf P, Longrois D, Combes A, Leprince P. Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study. THE LANCET RESPIRATORY MEDICINE 2021; 9:851-862. [PMID: 33887246 PMCID: PMC8055207 DOI: 10.1016/s2213-2600(21)00096-5] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 01/08/2023]
Abstract
Background In the Île-de-France region (henceforth termed Greater Paris), extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) was considered early in the COVID-19 pandemic. We report ECMO network organisation and outcomes during the first wave of the pandemic. Methods In this multicentre cohort study, we present an analysis of all adult patients with laboratory-confirmed SARS-CoV-2 infection and severe ARDS requiring ECMO who were admitted to 17 Greater Paris intensive care units between March 8 and June 3, 2020. Central regulation for ECMO indications and pooling of resources were organised for the Greater Paris intensive care units, with six mobile ECMO teams available for the region. Details of complications (including ECMO-related complications, renal replacement therapy, and pulmonary embolism), clinical outcomes, survival status at 90 days after ECMO initiation, and causes of death are reported. Multivariable analysis was used to identify pre-ECMO variables independently associated with 90-day survival after ECMO. Findings The 302 patients included who underwent ECMO had a median age of 52 years (IQR 45−58) and Simplified Acute Physiology Score-II of 40 (31−56), and 235 (78%) of whom were men. 165 (55%) were transferred after cannulation by a mobile ECMO team. Before ECMO, 285 (94%) patients were prone positioned, median driving pressure was 18 cm H2O (14−21), and median ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen was 61 mm Hg (IQR 54−70). During ECMO, 115 (43%) of 270 patients had a major bleeding event, 27 of whom had intracranial haemorrhage; 130 (43%) of 301 patients received renal replacement therapy; and 53 (18%) of 294 had a pulmonary embolism. 138 (46%) patients were alive 90 days after ECMO. The most common causes of death were multiorgan failure (53 [18%] patients) and septic shock (47 [16%] patients). Shorter time between intubation and ECMO (odds ratio 0·91 [95% CI 0·84−0·99] per day decrease), younger age (2·89 [1·41−5·93] for ≤48 years and 2·01 [1·01−3·99] for 49–56 years vs ≥57 years), lower pre-ECMO renal component of the Sequential Organ Failure Assessment score (0·67, 0·55−0·83 per point increase), and treatment in centres managing at least 30 venovenous ECMO cases annually (2·98 [1·46–6·04]) were independently associated with improved 90-day survival. There was no significant difference in survival between patients who had mobile and on-site ECMO initiation. Interpretation Beyond associations with similar factors to those reported on ECMO for non-COVID-19 ARDS, 90-day survival among ECMO-assisted patients with COVID-19 was strongly associated with a centre's experience in venovenous ECMO during the previous year. Early ECMO management in centres with a high venovenous ECMO case volume should be advocated, by applying centralisation and regulation of ECMO indications, which should also help to prevent a shortage of resources. Funding None.
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Affiliation(s)
- Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Matthieu Schmidt
- Intensive Care Unit, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Maharajah Ponnaiah
- Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Henri Mondor Hospital, AP-HP, University Paris Est Créteil, Créteil, France
| | - Marylou Para
- Department of Cardiovascular Surgery and Transplantation, Bichat Hospital, AP-HP, Paris, France; University of Paris, UMR 1148, Laboratory of Vascular Translational Science, Paris, France
| | - Julien Guihaire
- Department of Cardiac Surgery, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Edouard Sage
- Department of Thoracic Surgery and Lung Transplantation, Hôpital Foch, Suresnes, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, Paris University, INSERM UMRS-1144, Paris, France
| | - Pierrick Cronier
- Intensive Care Unit, Grand Hôpital du Sud Francilien, Corbeil, France
| | - Jonathan Zarka
- Intensive Care Unit, Grand Hôpital de l'Est Francilien, Jossigny, France
| | - Daniel Da Silva
- Medical Intensive Care Unit, Hôpital Delafontaine, Saint Denis, France
| | - Sebastien Besset
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, Colombes, France
| | | | - Igor Lacombat
- Intensive Care Unit, Jacques Cartier Hospital, Massy, France
| | - Nicolas Mongardon
- Department of Anesthesiology and Intensive Care, Henri Mondor Hospital, AP-HP, University Paris Est Créteil, Créteil, France
| | - Christian Richard
- Intensive Care Unit, Bicêtre Hospital, AP-HP, Paris Saclay University, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive care, Bicêtre Hospital, AP-HP, Paris Saclay University, France
| | - Charles Cerf
- Intensive Care Unit, Hôpital Foch, Suresnes, France
| | - Gabriel Saiydoun
- Department of Cardiac Surgery, Henri Mondor Hospital, AP-HP, University Paris Est Créteil, Créteil, France
| | - Romain Sonneville
- Intensive Care Unit, Bichat Hospital, AP-HP, Paris, France; University of Paris, UMR 1148, Laboratory of Vascular Translational Science, Paris, France
| | | | - Patrick Nataf
- Department of Cardiovascular Surgery and Transplantation, Bichat Hospital, AP-HP, Paris, France
| | - Dan Longrois
- University of Paris, UMR 1148, Laboratory of Vascular Translational Science, Paris, France; Department of Anaesthesia and Intensive Care, Bichat-Claude Bernard Hospital, AP-HP, INSERM U1148, Paris, France
| | - Alain Combes
- Intensive Care Unit, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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24
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Hou X, Hu W, Russell L, Kuang M, Konge L, Nayahangan LJ. Educational needs in the COVID-19 pandemic: a Delphi study among doctors and nurses in Wuhan, China. BMJ Open 2021; 11:e045940. [PMID: 33837108 PMCID: PMC8042588 DOI: 10.1136/bmjopen-2020-045940] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/30/2021] [Accepted: 02/22/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To identify theoretical and technical aspects regarding treatment, prevention of spread and protection of staff to inform the development of a comprehensive training curriculum on COVID-19 management. DESIGN Cross-sectional study. SETTING Nine hospitals caring for patients with COVID-19 in Wuhan, China. PARTICIPANTS 134 Chinese healthcare professionals (74 doctors and 60 nurses) who were deployed to Wuhan, China during the COVID-19 epidemic were included. A two-round Delphi process was initiated between March and May 2020. In the first round, the participants identified knowledge, technical and behavioural (ie, non-technical) skills that are needed to treat patients, prevent spread of the virus and protect healthcare workers. In round 2, the participants rated each item according to its importance to be included in a training curriculum on COVID-19. Consensus for inclusion in the final list was set at 80%. PRIMARY OUTCOME MEASURES Knowledge, technical and behavioural (ie, non-technical) skills that could form the basis of a training curriculum for COVID-19 management. RESULTS In the first round 1398 items were suggested by the doctors and reduced to 67 items after content analysis (treatment of patients: n=47; infection prevention and control: n=20). The nurses suggested 1193 items that were reduced to 70 items (treatment of patients: n=49; infection prevention and control: n=21). In round 2, the response rates were 82% in doctors and 93% in nurses. Fifty-eight items of knowledge, technical and behavioural skills were agreed on by the doctors to include in the final list. For the nurses, 58 items were agreed on. CONCLUSIONS This needs assessment process resulted in a comprehensive list of knowledge, technical and behavioural skills for COVID-19 management. Educators can use these to guide decisions regarding content of training curricula not only for COVID-19 management but also in preparation for future viral pandemic outbreaks.
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Affiliation(s)
- Xun Hou
- Clinical Competence Training Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Gastrointestinal Surgery Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjie Hu
- Clinical Competence Training Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Hepatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lene Russell
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for HR and Education, The Capital Region of Denmark, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark
| | - Ming Kuang
- Department of Hepatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for HR and Education, The Capital Region of Denmark, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Leizl Joy Nayahangan
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for HR and Education, The Capital Region of Denmark, Copenhagen, Denmark
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25
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Abstract
PURPOSE OF REVIEW The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events. RECENT FINDINGS In the 21st century, there have already been several outbreaks of infectious diseases that have led to mass casualties creating ICU strain, providing multiple opportunities for hospitals and hospital systems to prepare their ICUs for future events. Unfortunately, the sheer scale and rapidity of the SARS-CoV-2 pandemic led to overwhelming strain on every aspect of ICU disaster preparedness. Yet, by analyzing experiences of hospitals throughout the first 7 months of the current pandemic in the areas of infection control, equipment preparedness, staffing strategies, ICU spatial logistics as well as acute and postacute treatment, various important lessons have already emerged that will prove critical for successful future ICU preparedness. SUMMARY Preemptive planning, beginning with the early identification of staffing resources, supply chains and alternative equipment sources, coupled with strong infection control practices that also provide for the flexibility for evolving evidence is of utmost importance. However, there is no single approach that can be applied to every health system.
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Affiliation(s)
- Gavin Harris
- Divisions of Pulmonary Allergy and Critical Care Medicine and Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amesh Adalja
- Johns Hopkins Center for Health Security, Bloomberg School of Public Health, Baltimore, Maryland, USA
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26
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Kichloo A, Kumar A, Amir R, Aljadah M, Farooqi N, Albosta M, Singh J, Jamal S, El-Amir Z, Kichloo A, Lone N. Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic. World J Crit Care Med 2021; 10:1-11. [PMID: 33505868 PMCID: PMC7805254 DOI: 10.5492/wjccm.v10.i1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/07/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Akshay Kumar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15260, United States
| | - Rawan Amir
- Department of Internal Medicine, University of Maryland, Baltimore, MD 20742, United States
| | - Michael Aljadah
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Najiha Farooqi
- Department of Surgery, Central Michigan University, Saginaw, MI 48603, United States
| | - Michael Albosta
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Jagmeet Singh
- Department of Nephrology and Transplant Nephrology, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Shakeel Jamal
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Zain El-Amir
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Akif Kichloo
- Department of Anesthesiology and Critical Care, Saraswathi Institute of Medical Sciences, Uttar Pradesh 245304, India
| | - Nazir Lone
- Department of Pulmonology and Critical Care, Northwell Health, Riverhead, NY 11901, United States
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27
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COVID-19 and Extracorporeal Membrane Oxygenation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1353:173-195. [DOI: 10.1007/978-3-030-85113-2_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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28
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Fiest KM, Krewulak KD, Plotnikoff KM, Kemp LG, Parhar KKS, Niven DJ, Kortbeek JB, Stelfox HT, Parsons Leigh J. Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice. BMC Med 2020; 18:404. [PMID: 33334347 PMCID: PMC7746486 DOI: 10.1186/s12916-020-01871-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/25/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks. METHODS We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design. RESULTS From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason. CONCLUSIONS This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.
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Affiliation(s)
- Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Kara M Plotnikoff
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Laryssa G Kemp
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - John B Kortbeek
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Anaesthesia, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Jeanna Parsons Leigh
- Faculty of Health, School of Health Administration, Dalhousie University, 5850 College Street, Halifax, Nova Scotia, B3H4R2, Canada.
- Department of Critical Care Medicine, Faculty of Medicine, Dalhousie University, 6299 South St, Halifax, Nova Scotia, B3H4R2, Canada.
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29
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Jozwiak M, Chiche JD, Charpentier J, Ait Hamou Z, Jaubert P, Benghanem S, Dupland P, Gavaud A, Péne F, Cariou A, Mira JP, Nguyen LS. Use of Venovenous Extracorporeal Membrane Oxygenation in Critically-Ill Patients With COVID-19. Front Med (Lausanne) 2020; 7:614569. [PMID: 33363190 PMCID: PMC7758460 DOI: 10.3389/fmed.2020.614569] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/19/2020] [Indexed: 01/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) related to Coronavirus disease (COVID-19) is associated with high mortality. It has been suggested that venovenous extracorporeal membrane oxygenation (ECMO) was suitable in this indication, albeit the effects of ECMO on the mechanical respiratory parameters have been scarcely described. In this case-series, we prospectively described the use of venovenous ECMO and its effects on mechanical respiratory parameters in eleven COVID-19 patients with severe ARDS. Implantation of ECMO occurred 6 [3–11] days after the onset of mechanical ventilation. At the time of ECMO implantation, all patients received neuromuscular blocking agents, three (27%) received inhaled nitric oxide and prone positioning was performed in all patients with 4 [3−5] sessions of PP per patient. Under ECMO, the tidal volume was significantly decreased from 6.1 [4.0–6.3] to 3.4 [2.5–3.6] mL/kg of predicted body weight and the positive end-expiratory pressure level was increased by 25 ± 27% whereas the driving pressure and the mechanical power decreased by 33 ± 25% and 71 ± 27%, respectively. The PaO2/FiO2 ratio significantly increased from 68 [58–89] to 168 [137–218] and the oxygenation index significantly decreased from 28 [26–35] to 13 [10–15]. The duration of ECMO was 12 [8–25] days. Nine (82%) patients experienced ECMO-related complications and the main complication was major bleeding requiring blood transfusions. Intensive care unit mortality rate was 55% but no patient died from ECMO-related complications. In COVID-19 patients with severe ARDS, venovenous ECMO allowed ultra-protective ventilation, improved oxygenation and should be considered in highly selected patients with the most severe ARDS.
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Affiliation(s)
- Mathieu Jozwiak
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Jean-Daniel Chiche
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Julien Charpentier
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France
| | - Zakaria Ait Hamou
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Paul Jaubert
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France
| | - Sarah Benghanem
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Pierre Dupland
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Ariane Gavaud
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Frédéric Péne
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Alain Cariou
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Jean-Paul Mira
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,Université de Paris, Paris, France
| | - Lee S Nguyen
- Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, Paris, France.,CMC Ambroise Paré, Research and Innovation, Neuilly-sur-Seine, France
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30
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COVID-19 Outbreak Resources Optimization: Rapid Adaptation of a Catheterization Laboratory Into a New Intensive Cardiac Care Unit. J Cardiovasc Nurs 2020; 36:88-90. [PMID: 33027136 DOI: 10.1097/jcn.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Yadaw AS, Li YC, Bose S, Iyengar R, Bunyavanich S, Pandey G. Clinical features of COVID-19 mortality: development and validation of a clinical prediction model. Lancet Digit Health 2020; 2:e516-e525. [PMID: 32984797 PMCID: PMC7508513 DOI: 10.1016/s2589-7500(20)30217-x] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic has affected millions of individuals and caused hundreds of thousands of deaths worldwide. Predicting mortality among patients with COVID-19 who present with a spectrum of complications is very difficult, hindering the prognostication and management of the disease. We aimed to develop an accurate prediction model of COVID-19 mortality using unbiased computational methods, and identify the clinical features most predictive of this outcome. Methods In this prediction model development and validation study, we applied machine learning techniques to clinical data from a large cohort of patients with COVID-19 treated at the Mount Sinai Health System in New York City, NY, USA, to predict mortality. We analysed patient-level data captured in the Mount Sinai Data Warehouse database for individuals with a confirmed diagnosis of COVID-19 who had a health system encounter between March 9 and April 6, 2020. For initial analyses, we used patient data from March 9 to April 5, and randomly assigned (80:20) the patients to the development dataset or test dataset 1 (retrospective). Patient data for those with encounters on April 6, 2020, were used in test dataset 2 (prospective). We designed prediction models based on clinical features and patient characteristics during health system encounters to predict mortality using the development dataset. We assessed the resultant models in terms of the area under the receiver operating characteristic curve (AUC) score in the test datasets. Findings Using the development dataset (n=3841) and a systematic machine learning framework, we developed a COVID-19 mortality prediction model that showed high accuracy (AUC=0·91) when applied to test datasets of retrospective (n=961) and prospective (n=249) patients. This model was based on three clinical features: patient's age, minimum oxygen saturation over the course of their medical encounter, and type of patient encounter (inpatient vs outpatient and telehealth visits). Interpretation An accurate and parsimonious COVID-19 mortality prediction model based on three features might have utility in clinical settings to guide the management and prognostication of patients affected by this disease. External validation of this prediction model in other populations is needed. Funding National Institutes of Health.
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Affiliation(s)
- Arjun S Yadaw
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yan-Chak Li
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sonali Bose
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ravi Iyengar
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Supinda Bunyavanich
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gaurav Pandey
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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32
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Raman L, Dalton HJ. Surveying the Scene: Timing Is Everything. Pediatr Crit Care Med 2020; 21:902-903. [PMID: 33009301 DOI: 10.1097/pcc.0000000000002518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Lakshmi Raman
- Pediatric Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Heidi J Dalton
- INOVA Fairfax Medical Center; Program Development and Research, ECLS; Pediatrics; and Heart and Vascular Institute Falls Church, VA
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33
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Di Nardo M, Dalle Ore A, Starr J, Cecchetti C, Amodeo A, Testa G. Ethics and extracorporeal membrane oxygenation during coronavirus disease 2019 outbreak. Perfusion 2020; 35:562-564. [PMID: 32580648 DOI: 10.1177/0267659120937545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Anna Dalle Ore
- Clinical Bioethics, Children's Hospital Bambino Gesù, Rome, Italy
| | - Joanne Starr
- Division of Cardiothoracic Surgery, CHOC Children's Hospital Orange County, Orange, CA, USA
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- ECMO and VAD Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Giuseppina Testa
- Pediatric Cardiac Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
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34
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Yadaw AS, Li YC, Bose S, Iyengar R, Bunyavanich S, Pandey G. Clinical predictors of COVID-19 mortality. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.05.19.20103036. [PMID: 32511520 PMCID: PMC7273288 DOI: 10.1101/2020.05.19.20103036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has affected over millions of individuals and caused hundreds of thousands of deaths worldwide. It can be difficult to accurately predict mortality among COVID-19 patients presenting with a spectrum of complications, hindering the prognostication and management of the disease. METHODS We applied machine learning techniques to clinical data from a large cohort of 5,051 COVID-19 patients treated at the Mount Sinai Health System in New York City, the global COVID-19 epicenter, to predict mortality. Predictors were designed to classify patients into Deceased or Alive mortality classes and were evaluated in terms of the area under the receiver operating characteristic (ROC) curve (AUC score). FINDINGS Using a development cohort (n=3,841) and a systematic machine learning framework, we identified a COVID-19 mortality predictor that demonstrated high accuracy (AUC=0.91) when applied to test sets of retrospective (n= 961) and prospective (n=249) patients. This mortality predictor was based on five clinical features: age, minimum O2 saturation during encounter, type of patient encounter (inpatient vs. various types of outpatient and telehealth encounters), hydroxychloroquine use, and maximum body temperature. INTERPRETATION An accurate and parsimonious COVID-19 mortality predictor based on five features may have utility in clinical settings to guide the management and prognostication of patients affected by this disease.
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Affiliation(s)
- Arjun S. Yadaw
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1215, New York, NY 10029, USA
| | - Yan-chak Li
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1498, New York, NY 10029, USA
| | - Sonali Bose
- Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Ravi Iyengar
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1215, New York, NY 10029, USA
| | - Supinda Bunyavanich
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1498, New York, NY 10029, USA
| | - Gaurav Pandey
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1498, New York, NY 10029, USA
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35
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Gawda R, Marszalski M, Molsa M, Piwoda M, Pietka M, Gawor M, Mielnicki W, Dyla A, Czarnik T. Implementation of veno-venous extracorporeal membrane oxygenation in a COVID-19 convalescent. Anaesthesiol Intensive Ther 2020; 52:253-255. [PMID: 32876414 PMCID: PMC10172959 DOI: 10.5114/ait.2020.97956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- Ryszard Gawda
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, University Hospital, Opole, Poland
| | - Maciej Marszalski
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, University Hospital, Opole, Poland
| | - Maciej Molsa
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, University Hospital, Opole, Poland
| | - Maciej Piwoda
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, University Hospital, Opole, Poland
| | - Marek Pietka
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, University Hospital, Opole, Poland
| | - Maciej Gawor
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, University Hospital, Opole, Poland
| | - Wojciech Mielnicki
- Anaesthesiology and Intensive Care Unit, District Hospital in Olawa, Poland
| | - Agnieszka Dyla
- Anaesthesiology and Intensive Care Unit, District Hospital in Olawa, Poland
| | - Tomasz Czarnik
- Department of Anesthesiology, Intensive Care and Regional ECMO Center, Institute of Medical Sciences, University of Opole, Opole, Poland
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